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. <br /> - City of Orono <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> �0�, Mailing Address: Permit number: <br /> /�v ,�j� PO Box 66 <br /> .il� O \ <br /> Crystal Bay, MN 55323-0066 Date received: <br /> � s� Received by: <br /> � �'�.��.'�' s.�I StreetAddress: <br /> '" �''� �' � 2750 Kelle Parkwa <br /> �`' o~ Y Y Plan review fee: <br /> L�kESHo4'� Orono, MN 55356 <br /> - Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This app�ication form must be completed in full and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: / <br /> Job Site Address: � �W�p� � � <br /> Will this be a Parade of Homes, Remodeler howcase Home or other Display Home? ❑ Yes o <br /> lf yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service will e <br /> required unless applicant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLI ANT INFORMATIO : � <br /> Name: � L- S r <br /> State License# E piration Date: ?j �� � <br /> Phone: — S office - s Z cell <br /> Mailing Address: Cit : ^ S ZIP: s p <br /> Contact Person: Applicant is: ontracto / Homeowner (Circle One) <br /> Email and/or Fax: ' S e�/' `, , <br /> PROPERTY OWNER I FORMATION: <br /> Name: �p� � <br /> Phone (day): S2- _ 2 � <br /> Address: � � Cit : ZIP: <br /> Email and/or Fax <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> �oor(s) ❑ Remodel MCWD review 8� permits <br /> ❑Water Damage <br /> ,�Window s Minnehaha Creek Watershed District(MCWD) <br /> ( ) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Sidin Deephaven, MN 55391 <br /> g ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> ❑ Re-roof Fax: 952-471-0682 <br /> ❑ Fire Damage www.minnehahacreek.orq <br /> Overall Project Description: e U �,�5 ` <br /> _Estimated Construction Valuation of Pro�e t(excluding land) $ "70, OD� Gt�xi�y�ac�q� <br /> �� <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this info ion is to ually update our records and records of other governmental agencies <br /> re uired b law. If ou refu e to su the information the a lic tion ma not be issued. <br /> ApplicanYs Signature: Date: <br /> Last Updated: 05-04-2009 <br />